One West Court Square, Suite325 Decatur, GA 30030 Phone: (404) 320-1472
Fax: (404) 320-0849 Website: Email:
ASSOCIATION FOR CLINICAL PASTORAL EDUCATION, INC.
Clinical MEMBERSHIP APPLICATION FORM
Clinical Membership is for persons who completed four or more units of CPE recognized by the ACPE. Clinical Members must also sign an Accountability for Ethical Conduct Policy Form (attached) and file it with the national office. All persons meeting a Certification Committee for readiness or candidacy must be a Clinical Member in good standing. Submit completed applications to .
Full Name:Click here to enter text.
Mailing Address:Click here to enter text.
Work phone:Click here to enter text.Home phone:Click here to enter text.
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Include your email address to be sent a login and password to the Members Only section of the ACPE website!
Home phone numbers are not published in ACPE Directories or listed on the webpage.
Current Membership:
Are you currently a member and upgrading to Clinical Membership?: Choose an item.
If you know your account number, please provide it: Click here to enter text.
Form of Payment:
Check or Money Order Amount: $ Click here to enter text.Check or Money Order #: Click here to enter text.
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All information must be completed in order to process charge payments.
Amex ☐ Discover ☐ Visa ☐ MasterCard ☐Charges $ Click here to enter text.
Card Acct #:Click here to enter text.
Expiration Date:Click here to enter text.
Name as Appears on Card:Click here to enter text.
Provide us with your CPE history:
DatesLevelCenterSupervisor
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For more than eight units, please provide a typed list on another page.
Optional Information: The ACPE is committed to attracting, developing, and advancing the most talented caregivers and students regardless of their race, sexual orientation, spiritual/religious practices, age, gender, disability status and any other dimension of diversity. The information below is not required. It is collected for statistical purposes to track the association’s progress of achieving a diverse membership. Thank you for taking the time to tell us about yourself!
Gender: ☐ Female ☐ Male ☐ Intersexed ☐ Transgendered Birthday:Click here to enter a date.
Faith Group:Click here to enter text.
Check all that apply:
☐ American Indian and Alaska Native☐Native Hawaiian and Other Pacific Islander
☐ Asian or Southeast Asian☐ White or Caucasian
☐ Black or African Descent☐ Other
☐ Hispanic or Latino
Don’t forget to complete the Accountability for Ethical Conduct Policy Report Form (next page)
to complete your application!
One West Court Square, Suite 325 Decatur, GA 30030 Phone: (404) 320-1472
Fax: (404) 320-0849 Website: Email:
ACCOUNTABILITY FOR ETHICAL CONDUCT POLICY
REPORT FORM
For the purposes of this Policy, "member" refers to: ACPE Supervisors, Associate Supervisors, Active RetiredSupervisors, SupervisoryCandidates, and Clinical Members.
I certify that (a) no discipline or corrective action arising from a complaint of unethical or felonious conduct has been imposed on me, and no complaint against me for unethical or felonious conduct is pending in a civil, criminal, ecclesiastical, employment, or another professional organization's forum; and, (b) I have never resigned, been transferred or terminated, nor negotiated a settlement from a position for reasons related to unethical or felonious conduct.
Date: Click here to enter a date.
Signature: Click here to enter text.
If the above cannot be certified, please provide an account of the complaint including the forum, the charges, and the final outcome. Provide the names of people involved in the process whom you authorize to provide full information to ACPE representatives.
Prior actions are not an automatic bar to ACPE membership. Each situation will be evaluated on its own merits by an Accountability Review Committee composed of the Executive Director, the Chair of the Professional Ethics Commission (PEC), the Chair of the Certification Commission, the PEC legal consultant, and a designated Board member.
ACPE has the right to extend or deny candidacy status or membership regardless of previous complaints, other forum's findings or subsequent remedial actions according to the judgment of the named representatives to the Accountability Review Committee on behalf of the Association. If denied, the applicant may resubmit an application at a later time. Decisions are final and binding on ACPE. (Attach pages if necessary.)
I understand that as a condition of membership in the Association for Clinical Pastoral Education I will provide to the Association timely notice of any complaint of unethical or felonious conduct filed against me. I agree to provide to the ACPE Professional Ethics Commission in a timely fashion the information it requests regarding the investigation, adjudication, dismissal or settlement of such complaint. Failure to report or provide accurate, full and truthful information may be grounds for discipline including removal of membership in the Association for Clinical Pastoral Education, Inc.
Date: Click here to enter a date.
Signature: Click here to enter text.
Current Membership Category: Click here to enter text.